James Fowler does it again. He has just published another terrific and useful paper, "Core principles in treating suicidal patients." This makes a terrific companion piece to his previous paper describing "guidelines for imperfect assessments" which I have raved about and recommend all the time. The current paper is elegant and straightforward. Dr. Fowler provides a rationale, evidence, and a treatment example for three core principles:

alliance building

enhancing curiosity about the function of suicidal thoughts and urge

enhancing experience and epxression of intense emotions

Voila! What more do you want? You have to put Dr. Fowler's name on your search engine alert list! I just added it to the reference list that I will distribute at my next Commitment to Living workshop.

In a 6-month follow-up study of 119 hospitalized adolescents, Yen and colleagues found that many traditional risk factors including psychiatric diagnoses and past attempts failed to prospectively predict suicidal behavior. Other factors, which the authors called "cross-cutting" (because they cut across many disorders) were more potent.

These findings have direct clinical implications and indirect prevention implications. From a clinical perspective, clinicians must be cautious in applying population-generated risk factors to clinical risk formulation. Clinical training in risk formulation should emphasize dynamic factors over diagnoses and history and involve thoughtful synthesis of a wide range of factors and individual circumstances. From a broader prevention perspective, the study provides additional building blocks in the argument for focusing on cross-cutting constructs such as emotion self-regulation in suicide prevention (see our recent population-based study identifying emotion self-regulation as a critical construct for youth suicide prevention). This emphasis on "cross-cutting" constructs has interesting intersections with NIMH's effort, represented by the Research Domain Criteria (RDoC) to shift research away from DSM diagnostic categories toward dimensional assessment of more fundamental and biologically verifiable constructs. These findings are also congruent with (though they do not directly support) strategies that reach further "upstream" in adolescent development to build core "cross-cutting" protective factors.

The New York Times published an article this week that readers of this blog should be aware of. The article is titled, Study Questions Effectiveness of Therapy for Suicidal Teenagers. The article reports on results from a study published in JAMA Psychiatry (the new name for Archives of General Psychiatry) by Matthew Nock and a team of outstanding scientists. The NYT headline is based mostly on the finding that:

...suicidal adolescents typically enter treatment before rather than after the onset of suicidal behaviors. This means that mental health professionals are not simply meeting with adolescents in response to their suicidal thoughts or behaviors, but that adolescents who are clinically severe enough to become suicidal more typically enter treatment before the onset of suicidal behaviors. There is no way to know from the NCS-A data how often this early intervention prevents the occurrence of suicidal behaviors that would otherwise have occurred but were not observed in our data. It is clear, though, that treatment does not always succeed in this way because the adolescents in the NCS-A who received treatment prior to their first attempt went on to make an attempt anyway. This finding is consistent with recent data highlighting the difficulty of reducing suicidal thoughts and behaviors among adolescents. (Nock et al, (2013) Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents, JAMA Psychiatry, ePub ahead of print, p. E9)

The Nock article is hefty and I have not yet fully digested it. So I will withhold judgement about the article's conclusions, and about whether the NYT article reported them fairly and accurately. However, I am pleased about the discussions that this study and the Times article have the potential to stimulate. One conversation is about how to improve the quality and effectiveness of treatment for at-risk adolescents. This is not a new conversation, but continues to be an important one. Another conversation I hope this NYT article will stimulate relates to broadening our view of what suicide prevention is. With some important exceptions (including some here in New York State), the dominant strategy in suicide prevention has been to identify youth who are suicidal and get them into treatment. As my mentor, Peter Wyman has demonstrated (Wyman et al, 2008) and this Nock article brings to the surface, these 'identify and refer' strategies are limited by a number of factors, including availability and acceptability of services, the length of time adolescents remain in services, the effectiveness of therapy, and adolescents' tendency not to disclose suicide concerns to adults (Pisani et al 2012). While I am committed as ever to improving the quality of screening, assessment, and treatment for at-risk adolescents (and help to train hundreds of clinicians each year), I do not expect that treatment services alone will be sufficient for reducing suicide in the population. For this reason, in my research I am pursuing youth suicide prevention strategies aimed at addressing risk and protective processes further "upstream" (a term I learned from Dr. Wyman). In an article soon to be published, I argue that we need new interventions that can flexibly reach a broader population of adolescents further upstream and that these will require making use of new delivery systems, designs, and technologies.

I look forward to studying the Nock article and to participating a discussion that could help stimulate the field to re-examine what "prevention" really means. Substance abuse prevention does not start with finding kids who are already taking drugs. Fire prevention doesn't start with the fire department. We need great fire departments and well-trained fire fighters, but fire protection engineering and public education make major conflagrations rare. Likewise, youth suicide prevention must focus more broadly then on adolescents who are already suicidal.

Clinicians, school personnel, parents and other adults share at least one thing in common: none of us can read minds. The only way we're going to know if an adolescent is considering suicide is if they tell us. My colleagues and I conducted a study examining some key correlates of help-seeking among adolescents who had seriously considered suicide. The results have been published in the Journal of Youth and Adolescence.

I love the title of J. Christopher Fowler's article that was published in the current issue (vol 49, issue 1) of Psychotherapy, "Suicide Risk Assessment in Clinical Practice: Pragmatic Guidelines for Imperfect Assessments." This practice review is thorough and wise. Fowler strikes just the balance between encouraging completeness and responsibility, and acknowledging the limits inherent in assessments of risk. Dr. Fowler also masterfully weaves in the importance of self-awareness on the part of the clinician, and gives constant attention to maintaining a caring, compassionate stance. Some selected quotations to whet your appetite for this article:

"Knowing that patients frequently deny suicidal thoughts before suicide attempt and death, clinicians should remain appropriately circumspect regarding declarations of safety when a patient recently expressed suicidal ideation, feelings of hopeless, desperation, and/or affective flooding. This does not mean we should adopt a suspicious or adversarial stance—on the contrary, curiosity, concern, and calm acceptance of the patient’s emotional and cognitive states may serve to enhance the therapeu- tic alliance, encourage the patient to directly explore her or his current distress, and aid in the accurate evaluation of current functioning."

"Before conducting a formal suicide assessment, clinicians should conduct an introspective review of recent stressful life events facing the patient, including recent ruptures in the thera- peutic alliance, and disturbances in social relationships (Truscott, Evans, & Knish, 1999). Maintaining a therapeutic stance of curiosity and concern (while simultaneously remaining open to the possibility that an alliance rupture may be a precipitant to the crisis) is difficult to sustain when anxieties are running high; however, communicating genuine curiosity and concern about the causes for their unbearable suffering is critical."

"When clinicians face a potential suicide crisis, they are multi- tasking and are usually in a state of heightened alert and anxiety. Under such stressful circumstances, it is easy to get swept up in personal emotional reactions and lose sight of the patient’s suffering and their efforts to communicate distress."

My only critique involves the absence of family system context. I would have liked to see some attention to the positive role that family members can play in the assessment process. The article does mention that the quality of family relationships is an important modifiable risk factor, which should be considered and may be the focus of clinical intervention. But most of the article, and the clinical approach advocated, has a decidedly individualistic bent. The article doesn't address how to involve friends and family members in the interview process, how to build their participation into the decision-making process, how the relational context influences decisions about how to respond to identified risk. For me this is an important gap, and a contribution that is still needed.

This gap notwithstanding, this article will instantly join the Bryan et al. means restriction article on my Top 10 Most-recommended List. In fact, the Fowler article could become my primary go-to reference when clinicians ask for reading on the subject.

From early on in my quest to understand the unique challenges mental health professionals face in working with patients at risk for suicide, I've wondered aloud about the things that make us the most nervous. I'm still working my way through a list of questions I posted based on my notes from a series of trainings I delivered across New York State. One that has kept coming up since that time is this one:

How do we handle individuals at risk who are only marginally involved in treatment-they miss more appointments than they make, but still come enough that they remain on our caseloads?

Mental health care was not organized to fit the way many people at risk utilize services. Much of outpatient mental health is organized around a fantasy that most patients will (1) Make an appointment ahead of time for an evaluation; (2) come to that appointment at the specified time; (3) make another appointment; (4) come to that appointment; (5) work on a signed treatment plan in between.

Now, that model probably does work well for some people. But for many individuals at risk, that level of organization and consistency is not congruent with their lives. If it were, they wouldn't need us! The situations that make professionals the most nervous are the ones where the patient (1) Makes an appointment. (2) Comes to the appointment later in the day or the next day crying and upset, hoping to be seen. (2) Misses the next appointment. (3) Makes it to one appointment with the psychiatrist. (4) Misses 2 of the next 3 appointments with the primary therapist (5) can't recall the treatment plan when asked about it. Naturally, clinicians get frustrated and wish the person would either sign-up or drop out.

But of course it's not the fault of the individual at risk that we're set up the way we are, or that all the empirically supported treatments assume the patient is actually in treatment. I've addressed this issue here, here, and here when I've talked about how to manage patients who violate the "social contract" of being a patient. But there's something distinctly anxiety-provoking about someone who is loosely connected to mental health services, compared with someone who actively refuses plans we suggest. It can be especially hard if the loosely-connected person only shows up when in crisis.

This won't be a surprise to those who have followed my posts, but my approach to the loosely connected person hinges on two core clinical tasks: connection, compassion, and documentation.

Connection means that we should have the bias of keeping people involved to the level they are able. I know that this is difficult in the context of productivity demands and limited resources. You can't have 80 people on your caseload who all miss 75% of appointments. But I think we should condition ourselves (and set up services) to have a least a few people like that because the resources might be well spent in being a bridge to life for the person.

Compassion is always core. It can be hard to feel and show compassion to someone in crisis when they haven't taken the least first step to try ideas you've given. It's easy to find yourself thinking, "Maybe if you came a little more often, you wouldn't be in this position." It's especially hard to find compassion for someone who is at-risk for suicide and not showing up because it feels like they could take us down with them. All of those thoughts are natural, and it shouldn't end there. Instead, we have to summon the courage to enter in to the suffering one more time, offering the main thing we can offer under these circumstances: a caring commitment to living.

Documentation is one way I get to that place. One barriers to compassion is fear. It takes courage to keep working with someone who has only one foot in the room--especially when they present with suicide risk. Part of every clinician's brain is occupied with worry under these circumstances--worry about losing a patient, worry about being blamed, worry about being sued. It's hard to have compassion for someone if you think they could ruin your life. Having an unassailable risk assessment and other supporting documentation can put the fearful part of the clinicians brain to rest and make way for the kind of compassionate connection the hurting patient really needs. In other words, one of the key purposes of documentation is to quiet fears that might interfere with caring--and with doing the right thing. Once you're confident about documentation, you can focus on doing what's best for the patient, instead of feeling cornered into defensive courses of action.

Connection, compassion, and documentation share at least one thing in common: they are easier said than done. Their importance is so obvious that it may be tempting for an experienced clinician to speed passed these concepts. Anyone NOT think connection, compassion and documentation are important? Of course not. But, as with most simple good ideas, there are complex barriers to implementing them. Each person has to identify his or her own barriers and find a way to build these principles in to every day practice.

Franklin Cook has started a suicide prevention news blog that looks very promising. Suicide Prevention News and Comment (SPNAC) is still young-- less than a month old--but already has some valuable information and insights. As the site's name suggests, most of the posts (several each week) are stimulated by news in the suicide prevention arena which Mr. Cook passes on, along with helpful and thoughtful commentary. The webiste has a three-column newspaper-style format, which could be welcoming and familiar to readers who are less experienced with blogs. I have added SPNAC to my blogroll, and look forward to reading more from this site.

Speaking of nomenclature, I'm increasingly growing mistrustful of the term "protective factors." It sounds very "evidence-based" to refer to "risk and protective factors" when discussing one's approach to risk assessment. However, I've noticed a subtle misunderstanding that has creeped in along with the popularity of these terms. Often, it sounds like some clinicians are thinking of risk and protective factors are two sides of the same coin or--better put--two sides of the same scale and you arrive at a formulation of risk by weighing one against the other. The potential mistake is to think that protective factors "cancel out" risk factors.

Although I have a section called "protective factors" in the map I use to teach about risk formulation and documentation, I am increasingly finding myself replacing these words in workshops with the awkward phrase, "Launching off point factors." What I mean to convey is that it is probably best to think of "protective factors" as factors that increase the likelihood of success for crisis and treatment planning, rather than factors that technically "protect" against risk previously identified. A distraught, intoxicated individual with suicidal ideation and a gun can have all the protective factors in the world and that doesn't change the risk one bit. These factors may, however, present opportunities to engage in crisis planning, develop a therapeutic relationship, and engage a supportive system, all of which create conditions in which risk can be addressed, and which could ultimately influence decisions about the most appropriate level of care.

In our next revision of risk-related documentation, I'm considering recommending that we get rid of the term "protective factors" altogether because of the danger that it can be misleading. I don't have a great substitute, unfortunately. Best I can come up with right now is "Opportunities for Crisis and Treatment Planning," but I wonder if an ordinary person coming to a section so-labelled would know what it meant. Needs more work.

At a recent workshop I presented, a senior colleague commented that our clinical vernacular needs a more apt phrase than "high risk" to describe individuals whose clinical and historical presentation suggests risk for suicide. "High risk for suicide," he pointed out, sounds like suicide is probable, when in fact the likelihood of suicide in any given "high risk" case is still low in absolute terms. So, I've been struggling to think about an alternative. "Elevated risk?" "Multiple indicators of risk?" I don't know. This is not the only area in clinical suicidology with nomenclature problems, but it's the one I need to figure out right now in order to make some recommendations for documentation standards in our department. If you have any ideas, please leave them in the comment section or use the contact page to email me.

A colleague pointed me to a Washington Post article describing an interactive suicide prevention video the Army has produced and will make mandatory for all soldiers. I experimented with the online demo of Beyond the Front, which shows scenes from the life two soldiers and allows the viewer to make choices that either lead toward or away from help and survival. The demo portion I reviewed focuses on the decision a distressed soldier faces in deciding to talk with the chaplain or not. I was impressed with the quality of the video and interested by the approach.

I am not expert enough in public awareness and mass media approaches to prevention to comment or speculate about how effective this video might be in preventing suicide in the Army. But I would like to comment on some intersections between the approach this video takes and some ideas about clinical practice.

To me, one of the most powerful aspects of this video is the way in which it leads the soldier-viewer to see him/herself as potentially at risk for suicide. The video gives the message "If you don't get help, your life could be in danger." Since the video is interactive, the viewer can actually make decisions (like keeping the distress or suicidal thoughts secret) that eventually lead to death.

From a clinical perspective, I have found that putting in front of a person--sometimes in a dramatic way--the danger he or she is in can actually help to kick in the person's survival instinct. It sounds strange to warn someone of danger when the danger is from oneself. But a question like this one can be sobering: "If there were nothing we could do to move life be more livable, how likely would you be to die?" I worked with someone who could not name a single reason why life could have worth or meaning and who could identify no chance for things to get better, but who, when asked that question, started talking about his son and two other people he wouldn't want to leave behind. Recently, I was pleased to hear a similar question encouraged in the ASIST approach to suicide prevention and intervention. An advanced variation of this question might even embed the prospect of hope within the danger question: "If there were nothing we could to help life be more livable--I think there are things, but let's say we didn't pursue them--If things continue like this, how likely would you be to die?"

It is strange and surprising to some clinicans that most people who are suicidal (and I would venture to say some who actually kill themselves) don't want to die. Many people who have survived near lethal suicide attempts have reported that. A participant in a workshop I gave several months ago illustrated this for me in a compelling way. This participant had, at an earlier point in her life, attempted suicide. She had since recovered and pursued education in the mental health field. In sharing her subjective experience of the suicidal wish, she said, "I never wanted to kill myself. I just wanted to kill the pain." What a gift. Clinicians should be aware of this and look for ways to simultaneously connect with the suffering and activate the part of every person that desires life.

My lasttwo posts focused on means restriction--the aim of preventing suicide by reducing a person's access to a quick and lethal suicide method. The Golden Gate Bridge Physical Suicide Deterrent Project has been a highly publicized (and controversial) state effort to determine out the best way to balance the imperative of saving lives by erecting a physical barrier on the bridge and the desire to protect the beauty and touristic appeal of this national landmark. On October 10, Board of Directors voted to pursue the construction of an steel net that would extend 20 feet on either side of the bridge. Today I came across a post at PsychCentral by Dr. John M. Grohol describing how this proposed net would work. I found the article interesting and thought I'd pass it on.

I've had a nice response to the brief commentary I posted in conjunction with a link to the NY Times article about means restriction. In light of that, I thought I'd post a link to the a site called Means Matter, which is published by the Harvard Injury Control Research Center. The site has summary pages called "Taking Action" for families, communities, and clinicians.

The talking action page for clinicians is worth reading for any clinician, and could be especially useful to primary care providers. I'm thinking a lot about primary care right now because (a) primary care psychology has beeen a focus of my career and I have a deep respect for the breadth of responsibility primary care providers carry, including in suicide prevention (b) I'm still pondering the recent question I considered about self-trasport and (c) I'm presenting a talk titled "Tips for Suicide Risk Assessment and Response in Primary Care" next month at the Highland Family Medicine center here in Rochester.

I havementionedquiteafew NY Times articles in this blog because I think they cover suicide really well. Last month they published a piece in the NY Times Magazine that I keep recommending to people in informal and clinical discussions, so I thought I'd link to it here. Many thanks to my colleague Bill Watson for first alerting me to the article.

The Urge To End It, by Scott Anderson, is a stunning piece. Well-written, and well-researched, it challenges the stereotype that suicide is always well thought out, carefully planned, and the result of a conscious and un-ambivalent decision. He focuses on the impulsivity and momentary desperation involved in many suicide attempts, and raises awareness about means restriction as a potent intervention.

For clinicians, there are several important take-home points and cautions:

Expressed suicidal ideation is only one part of an assessment of risk for suicide; impulsivity, high intensity stressors, and agitated emotional pain signal as much about risk as suicidal ideation.

We need to ask about available means and seek to disable lethal means whenever possible.

We need to advocate for public policy that promotes means restriction--this may save the life of someone in our care (or in our lives).

Ambivelance runs deep. Even in the moment of jumping, survivors report feeling regret, not wanting to die. We are built for living, and those who help distressed individuals have a powerful force on our side.

We need to ask about how bad the pain is and how intense the desire for escape, even (especially) with individuals who have not previously expressed suicidal ideation.

There are probably other lessons from Anderson's excellent article, including understanding more about the subjective experience of someone who attempts suicide. The article is not short, but you'll be rewarded for the time spent to read it all the way through.

A colleague forwarded me the following excellent question posted to a listserv:

One question that has been raised is how to handle an individual who reports willingness to voluntarily go to the ER for psychiatric assessment. Since trusting a questionably unstable and suicidal individual to present for treatment opens our agency and the patient up to considerable risk, I wanted to get input on this issue from professionals in the field.

My questions are: What is the process that you use when you genuinely believe an adult patient will voluntarily present her/him self for possible commitment/assessment? How do you manage patient risk and your own liability in this instance? (e.g . requiring family members to be involved; or requiring a signed written contract to present at the hospital, etc) What do you do to ensure/confirm that they do indeed go to the hospital? What do you do when they do not go to the hospital, as agreed?

I'm looking for both a description of specific steps that you take and what variables you take into consideration as you decide what to do in this case.

This is an excellent question for several reasons:

the writer wants to support patient agency, preferring in principle to go with the patients voluntary wishes, rather than become unnecessarily coercive.

the writer is correctly concerned about putting all eggs in the self-report basket. A person at risk who is not stable may not be able to follow through with intentions to get help. It is central to both really listen people in our care AND understand that self-report has limitations and has to be considered in context

the writer has shared honestly her concern about both patient safety and his/her own liability—almost everyone who works with individuals at risk has these dual concerns and needs to think openly about how to balance them.

This is such a good question that I wish I had put it on my docket of questions to blog about. And it relates as a follow-up question to one that is on that docket, "When it comes to hospitalizing isn’t it always best to “err on the side of caution”?

Here is my attempt to offer some principles for the assessment and documentation of a patient's agreement to voluntary actions:

Document assessment of reliability of self-report. When assessing and documenting self-report the following should be considered and noted:

past experience, if any with the patient as a reliable reporter or not. “Pt. has reliably followed through on medical decisions and plans in the past.”

evidence of psychosis, thought disorder, intoxication, extreme agitation or other factor that would put the person’s capacity to make decisions in question. If not, “Pt’s thinking is logical, coherent, and reasonable. Judgment is intact. No indication of impaired capacity to make decisions and follow through with them.”

degree of patient cooperation. Explicitly note that the person volunteered information, though s/he didn’t have to. “The patient has been open, cooperative, and collaborative in the assessment and planning process. There is little reason to doubt his/her sincerity in agreeing to seek help and additional evaluation.”

impulsivity. The greatest risk here would be that the person would all of a sudden feel overwhelmed with pain and impulsively kill him/herself. If there is not strong evidence of that kind of impulsivity (even if there has been some in the past) note that. “The patient has a past history of mild impulsive behavior, however, this was several years ago and under very different circumstances..."

Show your reasoning. The key to great documentation is to state each of the factors considered, then show that the plan came as a result of synthesizing these factors. This can come in a statement like “In light of these factors, the plan for voluntary self-transport seems reasonable and prudent.”

Say what you didn't do. Related to the previous point, it as as important to document the road NOT taken. This shows that you took the situation seriously and considered the full range of options.

A corollary to this principle is to note risks associated with alternative courses of action. “Involuntary transport has potential of violating the patient’s rights and of harming the patient’s opportunity to benefit from hospitalization. The risk associated with involuntary transport outweigh the relatively small risk that the patient will precipitously abandon our plan and harm him/herself.”

Document consultation. Much more consultation occurs in primary care than is ever documented. This would be a time to do it. One line is sufficient: “Discussed case with Dr. X who concurred with the plan.”

Note that each of these points needs only a sentence or bullet-point, and not all will be applicable in every circumstance.

I'd be interested in feedback and ideas from who employs these principles in their documentation. I would also be interested in reading comments with other ideas about how to address the situation the questioner described.

I've returned from a fascinating series of trips to two New York State psychiatric facilities (St. Lawrence Psychiatric and Pilgrim Psychiatric), as part of a project I'm working on with the Office of Mental Health. I learned a great deal from talking about suicide risk with over 500 clinicians from a variety of disciplines and settings--psychologists, RNs, case managers, social workers, psychiatrists, mobile crisis clinicians, family therapists and others. It would be hard to find a group of professionals with more experience working with individuals at-risk, and the questions, comments, and concerns the participants contributed matched that level of experience.

I have made some notes about issues that were raised by clinicians, and plan to blog my thoughts about these in coming months as I get pockets of time to reflect on my travels. As I have stated before, I think it's important for educational initiatives to map closely onto the real-life concerns of clinicians, rather than simply reflecting content that experts deem important. Here are a few concerns and questions that I hope to think more about when I have time:/

When it comes to hospitalizing isn't it always best to "err on the side of caution?"

Why are we focusing on suicide so much when the people we work with have so many other problems?

Why are we focusing on suicide when it's so rare and most people who die by suicide weren't in treatment when they die?

How do we handle individuals at risk who are only marginally involved in treatment-they miss more appointments than they make, but still come enough that they remain on our caseloads?

Does doing a better job with risk for suicide always mean more work and writing?

Is there anyone for whom it is not indicated to ask about suicidal thoughts?

How often should we do a risk assessment?

What kinds of lawsuits have and have not been successful against clinicians in cases of completed suicide?

Even if we do everything right, can suicide really be prevented?

Along the lines of that last question, several clinicians shared moving stories about ways in which suicide has touched their lives, personally and professionally. It is always so sad to hear about these deaths, and so encouraging to hear that some of the ideas I brought for discussion felt relevant to these experiences.

A big thanks to the professionals at OMH, St. Lawrence, and Pilgrim who supported and hosted me during these trips. And to the clinicians at both facilities who made these trainings so stimulating and enjoyable.